As part of a wider quality improvement project (QIP) aiming to improve trainees’ experiences with ‘Raising Concerns’ in a large mental health trust, we sought to improve the trainee representative (rep) structure. This would give trainees more transparent processes and provide intermediaries by which to raise concerns. Based on change ideas generated from our driver diagram, roles were created to coordinate meetings and represent specific groups of trainees and on-call rotas.

Prior to August 2022, there were an undefined number of ‘Senior House Officer’ (SHO) reps who were recruited informally by the Post-Graduate Medical Education Team. The duties of these reps were not clearly detailed. As part of our first ‘Plan, Do, Study, Act’ (PDSA) cycle, we identified groups of trainees that needed additional representation (International Medical Graduates [IMGs], Less than Full Time trainees [LTFT]) and introduced a Wellbeing Rep to cover all training grades. Specifically for SHOs, we introduced three core roles (Rota/Placement, Inclusion, and Social) and individual roles for the six on-call rotas. Following the implementation of this rep structure, we gathered quantitative data, including whether trainees had utilised the reps and how effective they were in raising concerns, and qualitative feedback. We gathered data from both the reps and the whole cohort of trainees. We then started another PDSA cycle in August 2023.

On a 1–5 scale (5 = very effective), the average response from trainees for how effective the trust reps were in supporting raising concerns was 3.8 (5 responders), with no trainees who responded feeling that any of the rep roles needed restructuring. However, the rep survey highlighted that the following roles needed restructuring: Rota/Placement rep, Social rep, and Rota reps. The Rota/Placement role was highlighted as being unnecessary due to the existence of individual rota reps, but there was a need for a ‘lead’ rep to coordinate rep meetings and induction. Unfortunately, a Social rep was not recruited, however it was identified that due to the importance of the role more than one trainee may be required to arrange social events.

Overall, the trainee response to the new rep structure has been neutral/effective, but we hope to obtain more responses in the next PDSA cycle. The rep feedback highlighted the need for coordinator roles to improve cohesion. The results have informed change ideas which we implemented in August 2023. The second PDSA cycle will be completed in July 2024.

Understanding characteristics of healthcare personnel (HCP) with SARS-CoV-2 infection supports the development and prioritization of interventions to protect this important workforce. We report detailed characteristics of HCP who tested positive for SARS-CoV-2 from April 20, 2020 through December 31, 2021.

CDC collaborated with Emerging Infections Program sites in 10 states to interview HCP with SARS-CoV-2 infection (case-HCP) about their demographics, underlying medical conditions, healthcare roles, exposures, personal protective equipment (PPE) use, and COVID-19 vaccination status. We grouped case-HCP by healthcare role. To describe residential social vulnerability, we merged geocoded HCP residential addresses with CDC/ATSDR Social Vulnerability Index (SVI) values at the census tract level. We defined highest and lowest SVI quartiles as high and low social vulnerability, respectively.

Our analysis included 7,531 case-HCP. Most case-HCP with roles as certified nursing assistant (CNA) (444, 61.3%), medical assistant (252, 65.3%), or home healthcare worker (HHW) (225, 59.5%) reported their race and ethnicity as either non-Hispanic Black or Hispanic. More than one third of HHWs (166, 45.2%), CNAs (283, 41.7%), and medical assistants (138, 37.9%) reported a residential address in the high social vulnerability category. The proportion of case-HCP who reported using recommended PPE at all times when caring for patients with COVID-19 was lowest among HHWs compared with other roles.

To mitigate SARS-CoV-2 infection risk in healthcare settings, infection prevention, and control interventions should be specific to HCP roles and educational backgrounds. Additional interventions are needed to address high social vulnerability among HHWs, CNAs, and medical assistants.

To characterize residential social vulnerability among healthcare personnel (HCP) and evaluate its association with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection.

Case–control study.

This study analyzed data collected in May–December 2020 through sentinel and population-based surveillance in healthcare facilities in Colorado, Minnesota, New Mexico, New York, and Oregon.

Data from 2,168 HCP (1,571 cases and 597 controls from the same facilities) were analyzed.

HCP residential addresses were linked to the social vulnerability index (SVI) at the census tract level, which represents a ranking of community vulnerability to emergencies based on 15 US Census variables. The primary outcome was SARS-CoV-2 infection, confirmed by positive antigen or real-time reverse-transcriptase– polymerase chain reaction (RT-PCR) test on nasopharyngeal swab. Significant differences by SVI in participant characteristics were assessed using the Fisher exact test. Adjusted odds ratios (aOR) with 95% confidence intervals (CIs) for associations between case status and SVI, controlling for HCP role and patient care activities, were estimated using logistic regression.

Significantly higher proportions of certified nursing assistants (48.0%) and medical assistants (44.1%) resided in high SVI census tracts, compared to registered nurses (15.9%) and physicians (11.6%). HCP cases were more likely than controls to live in high SVI census tracts (aOR, 1.76; 95% CI, 1.37–2.26).

These findings suggest that residing in more socially vulnerable census tracts may be associated with SARS-CoV-2 infection risk among HCP and that residential vulnerability differs by HCP role. Efforts to safeguard the US healthcare workforce and advance health equity should address the social determinants that drive racial, ethnic, and socioeconomic health disparities.

Raising a concern is an integral duty for a doctor. The General Medical Council guidelines on Good Medical Practice state that a culture should be promoted that allows “all staff to raise concerns openly and safely”. Appointment of Postgraduate Doctors in Training to Representative (Rep) positions can be an effective way to allow trainee voices to be heard. Here we present the results of a Development Half-Day created to empower Reps with the knowledge and confidence to represent peers effectively within a large mental health Trust. The training session was identified as a ”change idea” in a wider Quality Improvement Project (QIP) seeking to improve trainee confidence in raising concerns.

16 Postgraduate Doctors in Training Reps were invited to attend a Development Half-Day in November 2022. The day included talks on their roles and responsibilities, respectful challenge and maintaining well-being.

Quantitative and qualitative data were gathered using anonymous questionnaires completed before and after the session. The questionnaire contained 4 questions asking them to rate their knowledge of their role as a rep and confidence in raising trainee concerns. This was quantified using a 1-10 scale for each question with 1 being lowest confidence/knowledge and 10 being highest. Mean scores and standard deviations were calculated. A paired one-tailed t-test was used to assess the statistical significance of the difference in pre- and post-session scores.

9 Reps attended the Development Half-Day and completed the pre- and post-session questionnaires.

There was a statistically significant improvement between pre- and post-session scores for all questions (all p values <0.05). Importantly there was a significant increase in the confidence felt by reps in knowing where and who to raise trainee concerns to (p < 0.05).

Qualitative feedback indicated that attendees found the session useful and they appreciated that it was in-person. The only suggestion for improvement was for the session to have been held earlier, closer to when reps were initially appointed; this will be a change that will be implemented in the next “Plan, Do, Study, Act” cycle of the QIP.

Implementation of a Development Half-Day for Trainee Reps was shown to have a significantly positive impact on their confidence in their roles and their ability to respectively challenge seniors. The Reps additionally reported being better equipped at knowing where and who to raise concerns to. This will hopefully aid in their ability to signpost and empower other trainees to do the same.

As part of a wider Quality Improvement Project aiming to improve trainees’ experiences with ‘Raising Concerns’ in a large mental health trust, we sought to improve induction processes to make information on raising concerns more accessible when starting a new post. Based on change ideas generated from our driver diagram, peer-delivered information was identified as a useful tool, so a trainee-led session was introduced to the induction programme.

A 60-minute trainee-led session was integrated into the induction programme for Postgraduate Doctors in Training in August 2022. The session included sections on raising concerns, on-call advice and rota information. Following the induction, as part of our “Plan, Do, Study, Act” (PDSA) cycle, we sent a questionnaire to gather data from trainees, which covered quantitative measures, including overall helpfulness of the session and effectiveness of information on ‘raising concerns’, and qualitative feedback for how to improve the session. The session was replicated at both the December 2022 and February 2023 inductions, incorporating the feedback from each previous session.

On a 1-5 scale (5 = strongly agree), the average response for how helpful the trainee-led induction session was 4.5 from both the August and December 2022 inductions. 4 out of 6 responders from the August 2022 induction specifically mentioned the information on raising concerns as being particularly helpful. There was also feedback on improvements that could be introduced, such as increasing the amount of time for the session to allow for more questions. When asked to rate the helpfulness of the ‘raising concerns’ section, the average response was 4.83 and 4.50 for August and December 2022 inductions, respectively. Following the feedback from August 2022, we implemented changes to increase the duration to 90 minutes and include trainee reps in a separate ‘Question and Answer’ session. Unfortunately, there were only 2 responders to the December 2022 questionnaire due to a small intake, so we will evaluate data from February 2023 induction to analyse the effectiveness of changes made to the session and assess the need for further improvements.

Overall, the response to our trainee-led induction session has been positive, with good feedback both for the whole session and specifically relating to ‘raising concerns’. It has highlighted trainees’ appreciation for peer-delivered information and the need for more time in this session. The questionnaire from February 2023 induction will give more data on whether our improvements have been effective and provide ideas for future PDSA cycles.

Raising concerns is a duty for all doctors. However, a scoping exercise within a large mental health Trust demonstrated that trainees experience difficulties in raising both patient safety and training concerns. As part of a trainee-led quality improvement (QI) project within this Trust, our aim was to develop a pulse survey to capture the current likelihood of trainees raising concerns and factors influencing this.

An online survey was developed using ‘plan do study act’ (PDSA) methodology. The initial draft was informed by data from the Autumn 2021 scoping exercise. The survey was refined using a collaborative trainee-led approach. It was tested by trainees involved in the QI project followed by two other trainees and was revised accordingly.

Trainees across all training grades were invited to complete the survey through various communication channels. The pulse survey will be repeated monthly with a two-week response window.

Ten trainees out of 103 responded to the first pulse survey open from 18th to 31st January 2023 (response rate 9.7%). Seven respondents were core trainees and three were higher trainees.

Respondents were more likely to raise patient safety concerns than training concerns (average score of 3.8 out of 5, where 5 equals ‘very likely’, versus 3.4 out of 5 respectively). Of the three respondents who had experienced a patient safety concern in the past 2 weeks, only two had used any existing process to raise it. These data were replicated for training concerns.

No respondents were confident that effective action would be taken if they raised a training concern, while less than half of respondents were confident that effective action would be taken if it were a patient safety concern.

The reasons for the low response rate are likely varied. However, there may be some similar underlying reasons for low engagement in surveys and low engagement in raising concerns. Given this, a more negative picture of trainees’ likelihood of raising concerns may have been portrayed if more trainees engaged in the survey.

Engaging trainees to provide insight into their likelihood of raising concerns is challenging. Despite the low response rate, this initial pulse survey demonstrated that trainees continue to experience barriers to raising concerns. PDSA methodology will continue to be used to optimise the monthly pulse survey response rate. The key QI outcome measures will also be integrated into pre and post intervention surveys as a pragmatic approach to evaluate specific change ideas.

Individuals living with severe mental illness can have significant emotional, physical and social challenges. Collaborative care combines clinical and organisational components.

We tested whether a primary care-based collaborative care model (PARTNERS) would improve quality of life for people with diagnoses of schizophrenia, bipolar disorder or other psychoses, compared with usual care.

We conducted a general practice-based, cluster randomised controlled superiority trial. Practices were recruited from four English regions and allocated (1:1) to intervention or control. Individuals receiving limited input in secondary care or who were under primary care only were eligible. The 12-month PARTNERS intervention incorporated person-centred coaching support and liaison work. The primary outcome was quality of life as measured by the Manchester Short Assessment of Quality of Life (MANSA).

We allocated 39 general practices, with 198 participants, to the PARTNERS intervention (20 practices, 116 participants) or control (19 practices, 82 participants). Primary outcome data were available for 99 (85.3%) intervention and 71 (86.6%) control participants. Mean change in overall MANSA score did not differ between the groups (intervention: 0.25, s.d. 0.73; control: 0.21, s.d. 0.86; estimated fully adjusted between-group difference 0.03, 95% CI −0.25 to 0.31; P = 0.819). Acute mental health episodes (safety outcome) included three crises in the intervention group and four in the control group.

There was no evidence of a difference in quality of life, as measured with the MANSA, between those receiving the PARTNERS intervention and usual care. Shifting care to primary care was not associated with increased adverse outcomes.

There is definitive evidence for effectiveness of thrombectomy for acute stroke with large vessel occlusion (LVO). A clinical tool to identify patients with LVO is therefore required for effective triage and prehospital decision making. We developed the FAST VAN tool, which follows from the Heart and Stroke Foundation FAST stroke screen, with the addition of cortical features of vision, aphasia, and neglect, to differentiate from lacunar syndromes.

Consecutive acute stroke alerts initiated by emergency medical services (EMS) were prospectively analyzed from April 2017 to Jan 2021. FAST VAN signs were recorded by first responders who had received online education about the tool. These findings were compared to the presence or absence of LVO on CT angiography. Analysis was also performed by appropriateness for comprehensive stroke centers (CSC) transfer if no LVO was present. EMS providers were surveyed regarding ease of use in terms of learning the tool and using in real-world practice.

Data from 1080 consecutive acute strokes included 440 patients considered to have VAN signs by EMS. Fifty-four percent of VAN-positive patients showed LVO on CTA. Sensitivity, specificity, and accuracy were 86%, 75%, and 77%, respectively. In 204 false-positive cases, 143 (70%) were considered appropriate for evaluation at the CSC. EMS providers reported high satisfaction with learning and using the tool.

The FAST VAN tool for identification of LVO meets desired characteristics of an effective screening tool in ease of use, efficiency, and accuracy. Aphasia remains the most challenging cortical feature to identify accurately.

Wales has ambitious health, wealth, and innovation policies and a clear goal to use the economic muscle of the Welsh National Health Service (NHS) to support its strong life sciences sector. Health Technology Wales (HTW) has a clear remit to appraise technologies over the span of their lifecycle from innovation to obsolescence. HTW is collaborating with the Bevan Commission through their national Health Technology Exemplars (HTEs), which partners NHS and industry stakeholders to strengthen innovation within the Welsh health system.

Health technology assessment (HTA) methods were used to produce topic exploration reports for assessing the evidence underpinning applicant innovations. A “Dragons’ Den” expert panel was convened to select the successful HTEs.

Fourteen Bevan HTEs were awarded funds, which were matched by industry partners. Application of HTA methods resulted in more critical consideration of technology value propositions, including: developing pull models of innovation focused on delivering health technology solutions for current problems facing NHS Wales; supporting early dialogue between the NHS and industry partners around demonstrating evidence of improved patient outcomes; and focusing on transformative rather than incremental innovation. The most promising innovations will progress to rapid HTA, where the evidence generated will be used to develop guidance for NHS Wales.

HTA methods were productively deployed at the innovation phase of the technology lifecycle to support evidence-informed allocation of scarce innovation resources. In this way, HTW is working with key stakeholders to identify and offer early support to the most promising innovations, with the aim of expediting their adoption and realizing health benefits for patients as quickly as possible. The Bevan Commission has partnered with HTW to routinely build in HTA and evidence considerations in its future innovation calls and competitions. Thus, HTW has established a “feeder” pipeline for assessing bottom-up service-led innovations and encouraging evidence consideration throughout the lifecycle of innovative technologies.

The Frequent Attenders Programme is a joint initiative between Hertfordshire Rapid Assessment, Interface and Discharge service and the Emergency Department of the West Hertfordshire NHS Trust, which aims to divert frequent attenders from the emergency department by addressing their unmet needs. This paper describes the range of interventions put in place from the time that the service was set up in 2014 until the introduction of the new national Commissioning for Quality and Innovation 2017–2019, which tasked National Health Service trusts to improve services for people with mental health needs who present to Accident and Emergency. The terms emergency department and Accident and Emergency are used interchangeably, reflecting the practice in policy documents. A subsequent article will report on the impact of the Commissioning for Quality and Innovation in Hertfordshire.

Analysis of the interventions indicated a highly significant (P < 0.0001) mean reduction in attendances. Lower gains were made in patients whose primary presentations were alcohol-related. A failure to effect change in two patients led to a significant revision of their respective care plans, resulting in a subsequent reduction in their attendances.

An integrated approach to patients with complex presentations was associated with high levels of both patient and referrer satisfaction. It is hypothesised that dismantling the barriers between physical and mental health may lead to similar successes in frequent attenders in other in-patient and community medical and psychiatric services.

None.